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INTERIM UPDATE

ACOG PRACTICE BULLETIN SUMMARY

Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 204 (Replaces Practice Bulletin No. 134, May 2013)

For a comprehensive overview of these recommendations, the full-text Scan this QR code
version of this Practice Bulletin is available at http://dx.doi.org/10.1097/ with your smartphone
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version of this
Practice Bulletin.

Committee on Practice Bulletins—Obstetrics and Society for Maternal-Fetal Medicine.

This Practice Bulletin was developed by the American College of Obstetricians and Gynecologists Committee on Practice Bulletins—
Obstetrics and the Society for Maternal-Fetal Medicine Publications Committee with the assistance of Henry Galan, MD, and William
Grobman, MD.

INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect a limited, focused change to align with Com-
mittee Opinion No. 764, Medically Indicated Late-Preterm and Early-Term Deliveries, regarding delivery for fetal growth
restriction, and Committee Opinion No. 713, Antenatal Corticosteroid Therapy for Fetal Maturation. In addition, there are
updated data on delivery comparing changes in the ductus venosus Doppler versus fetal heart rate tracing changes. For
complete details on these updates, please see the full-text version.

Fetal Growth Restriction

Fetal growth restriction, also known as intrauterine growth restriction, is a common complication of pregnancy that
has been associated with a variety of adverse perinatal outcomes. There is a lack of consensus regarding terminology,
etiology, and diagnostic criteria for fetal growth restriction, with uncertainty surrounding the optimal management and
timing of delivery for the growth-restricted fetus. An additional challenge is the difficulty in differentiating between the
fetus that is constitutionally small and fulfilling its growth potential and the small fetus that is not fulfilling its growth
potential because of an underlying pathologic condition. The purpose of this document is to review the topic of fetal
growth restriction with a focus on terminology, etiology, diagnostic and surveillance tools, and guidance for
management and timing of delivery.

Clinical Management Questions

< How should pregnancies be screened for fetal growth restriction, and how is screening accomplished?
< How should women with a prior birth of a small for gestational age newborn be evaluated?
< Can fetal growth restriction be prevented?
< When should genetic counseling and prenatal diagnostic testing be offered in the case of fetal growth
restriction?
< How should a pregnancy complicated by fetal growth restriction be evaluated and managed?

390 VOL. 133, NO. 2, FEBRUARY 2019 OBSTETRICS & GYNECOLOGY

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and Gynecologists. Published by Wolters Kluwer Health, Inc.
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< What is the role of Doppler velocimetry in evaluating a pregnancy complicated by fetal growth
restriction?
< When should a growth-restricted fetus be delivered?
Recommendations
and Conclusions
The following recommendations and conclusions are
based on good and consistent scientific evidence
(Level A):
< Umbilical artery Doppler velocimetry used in con-
junction with standard fetal surveillance, such as
nonstress tests, or biophysical profiles, or both, is
associated with improved outcomes in fetuses in
which fetal growth restriction has been diagnosed.
< Antenatal corticosteroids are recommended if
delivery is anticipated before 33 6/7 weeks of ges-
tation because they are associated with improved
preterm neonatal outcomes. In addition, antenatal
corticosteroids are recommended for women in
whom delivery is anticipated between 34 0/7 and 36
6/7 weeks of gestation, who are at risk of preterm
delivery within 7 days, and who have not received
a previous course of antenatal corticosteroids.
< For cases in which delivery occurs before 32 weeks
of gestation, magnesium sulfate should be consid-
ered for fetal and neonatal neuroprotection.
< Nutritional and dietary supplemental strategies for
the prevention of fetal growth restriction are not
effective and are not recommended.
The following recommendations and conclusions are
based primarily on consensus and expert opinion
(Level C):
< Fetal growth restriction alone is not an indication for
cesarean delivery.
< The optimal timing of delivery of the growth-
restricted fetus depends on the underlying etiology
of the growth restriction (if known), the estimated
VOL. 133, NO. 2, FEBRUARY 2019
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and Gynecologists. Published by Wolters Kluwer Health, Inc.
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gestational age, and other clinical findings such as
antenatal fetal surveillance.
Proposed Performance Measure
Percentage of pregnant women with suspected fetal
growth restriction in whom a plan for assessment and
surveillance of fetal growth and well-being is initiated, if
delivery is not pursued at the time of diagnosis
Studies were reviewed and evaluated for quality
according to the method outlined by the U.S.
Preventive Services Task Force. Based on the highest
level of evidence found in the data, recommendations are
provided and graded according to the following
categories:
Level A—Recommendations are based on good and
consistent scientific evidence.
Level B—Recommendations are based on limited or
inconsistent scientific evidence.
Level C—Recommendations are based primarily on
consensus and expert opinion.
Full-text document published online on January 24, 2019.
Copyright 2019 by the American College of Obstetricians and
Gynecologists. All rights reserved. No part of this publication
may be reproduced, stored in a retrieval system, posted on the
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Official Citation
Fetal growth restriction. ACOG Practice Bulletin No. 204.
American College of Obstetricians and Gynecologists. Obstet
Gynecol 2019;133:e97–109.
Practice Bulletin No. 204 Summary 391
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of
care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by
calling the ACOG Resource Center.
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392 Practice Bulletin No. 204 Summary OBSTETRICS & GYNECOLOGY

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Unauthorized reproduction of this article is prohibited.